Expert Response #64

Circumcision is a contentious topic in pediatric health because the procedure has lifelong consequences for the patient receiving it, and parents must act as the substitute decision-makers for their children attempting to act in their best interest. “Best interest”, in this case, can have a variety of religious or ethnic connotations. I understand that in most jurisdictions, the authority that parents have is limited to situations that are medically necessary. This is a large portion of the dispute in which parents defer medical necessity for religious or cultural reasons. The crux of this ethical dilemma, then, is that there are situations where parents might request a circumcision for reasons that are nebulous in relation to what’s established as a medical necessity.

In response to this recommendation by the Paediatric Association, I think it’s important to make decisions on a case-by-case basis. The relevant literature is not conclusive on this topic, but there are many clues that support this approach. There are, for instance, certain advantages to be gained from this procedure for newborns, such as a decreased risk of contracting a sexually transmitted disease. Furthermore, medical necessity is not a settled dispute, so I think it’s unfair to impose a universal rule. There are cases, where it would be important to allow the patient to make their own choices when they are old enough to consent to the procedure. Of course, there are still complications that can arise in patients who choose circumcision in adolescence or adulthood, so elucidating the benefits and potential risks will need to be reviewed independently.

As a physician, it’s our job to provide the most unbiased and up-to-date information available at the time to respect the patient’s autonomy and best interests. Especially because these situations are not definite in my estimation, working together with the families of the child and other physicians will be an important part of deciding whether circumcision is a medical necessity, or whether breaching this rule is worth the potential risks. I would also say that it will be important to provide a list of pros and cons for the parent to consider. Educating them with resources that they can access on their own, and that I can provide for them in my office will facilitate a productive dialogue that will help them make a better decision. (386 words).

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